Immunodeficiency

Concept and classification

 What is Immunodeficiency?
 A failing of one or more of the body’s defensive
mechanisms resulting in morbidity or mortality.

 Any part of the immune system can be deficient cells,

proteins, signalling mechanisms…….

 The body is susceptible to infection by organisms that

meet with little or no resistance
 What is immunodeficiency?
In certain cases, other homeostatic systems in
the body will be disrupted by the defect.

Severity is variable.

Immunodeficiency may be Primary or

Secondary.
 Primary Immunodeficiency
• Mutations/deletions of genes governing stem
cell differentiation have been identified and
over 150 disorders have been identified.
• B-cell defects account for 50% of primary
immunodeficiency,
• T-cell defects for 30%, phagocytic deficiencies
18% and complement deficiencies 2%
 Primary Immunodeficiency
• The overall incidence of symptomatic primary
immunodeficiency is estimated to be
1/10,000.
• About 80% of patients are less than 20 years
old when diagnosed, because the majority of
cases are inherited or congenital. 70% occur in
males due to X-linked inheritance in many
syndromes
 Primary Immunodeficiency
• Primary immunodeficiency seen in paediatric
are physiologic hypo agammaglobulinemia of
infancy.
• transient hypo agammaglobulinemia of infancy.
• IgG subclass deficiency, partial antibody
deficiency with impaired polysaccharide
responsiveness (IPR) and
• selective IgA deficiency IgAD.
 Secondary Immunodeficiency:
Acquired
 Infection

Renal failure, or protein losing enteropathy

 Leukaemia, Lymphoma, Myeloma

 Extremes of age, certain drug therapies

HIV/AIDS and Tuberculosis

 Clinical features associated with
immunodeficiency
Feature frequency present and highly
suspicious:
 Chronic infection
 Recurrent infection (more than expected)
 Unusual microbial agents
 Incomplete clearing of infection
 Incomplete response to treatment
 Clinical features associated with
immunodeficiency
 Feature moderately suspicious
Diarrhea (chronic)
Growth failure
Recurrent abscesses
Recurrent osteomyelitis
 Feature associated with specific
immunodeficiency disorder
Telangiectasia
Partial albinism
 Classification of
Immunodeficiency Disorders
 Antibody(B cells) immunodeficiency
 Cellular(T cell)deficiencies
Combined Antibody-mediated(B cell) and
cell mediated(T cell) immunodeficiency
 Phagocytic disorders
 Complement deficiencies
Antibody (B cell) ID
1.X- linked agammaglobulinemia
2. Selective IgA deficiency
3. IgG Subclasses deficiency
4. Hyper – IgM
5. CVID
 What is X linked aggammaglobulinemia(XLA)

 First immunodeficiency described.

 Defect on the X chromosome affecting the B tyrosine

kinase gene.

 Results in an absence or severe reduction in B

lymphocytes and hence immunoglobulin of all types.
• Bruton's Agammaglobulinemia.

• The gene Bruton's tyrosine kinase (Btk) plays an

essential role in the maturation of B cells in the
bone marrow,

• and when mutated, immature pre-B lymphocytes

are unable to develop into mature B cells that
leave the bone marrow into the blood stream.
 Clinical Findings
 Symptoms appear at 6-9 months of age (after loss
of maternal Ig) .

 Sites of infection: mucous membranes, ear (otitis

media), lungs (bronchitis/pneumonia), blood
(sepsis), gut (Giardia, or enterovirus), skin, eyes,
meningitis.

 Mostly by S. pneumoniae, H. influenzae

Also seen: joint problems, kidney problems,
neutropenia, malignancy in older patients.

The diagnosis is probable when blood tests show the

complete lack of circulating B cells (determined by
the B cell marker CD 19 and/or CD 20),

As well as low levels of all antibody classes, including

IgG, IgA, IgM, IgE and IgD.
 Selective IgA Deficiency

Selective IgA deficiency is the most common

ID disorder.
The prevalence is about 1:700.
Pathogenesis : block in B cell differentiation is
due to intrinsic B cell defect
 IgA Deficiency
 Clinical feature: Recurrent sinopulmounary
infection, Gastrointestinal disorders, Allergy,
Cancer and Autoimmune disease.

IgA Deficiency and drug.

 Serum IgA<5mg/dl but normal IgM and IgG

 Immunopathogenesis :arrest in the B cell

differentiation.
 Selective IgG subclass deficiency
 Total serum IgG levels are normal

 One or more subclasses are below normal.

 IgG3 deficiency is the most common subclass in adults.

 IgG2 deficiency associated with IgA deficiency in children.

 Pathogenesis: abnormal B cell differentiation.

 Some individual have recurrent bacterial infection.

Common Variable Immunodeficiency

CVID
• CVID is characterized by
hypogammaglobulinemia
• Common variable immunodeficiency
(CVID) is a group of 20-30 PIDs which have
a common set of symptoms but with
different underlying causes.
 Causes and types
• The result of these defects is that the patient doesn't
produce sufficient antibodies in response to exposure
to pathogens.

• As a result, the patient's immune system fails to

protect them against common bacterial and viral
(and occasionally parasitic and protozoan) infections.

• The net result is that the patient is susceptible to

illness.
T cell deficiency
DiGeorge Syndrome
 DiGeorge Syndrome
 Defective development in thymus and
parathyroid that develop from third and
fourth Pharyngeal pouch

Thymic hypoplasia leading to variable

immunodeficiency. Other features:
Characteristic faces
22q11.2 deletion syndrome
Abnormal calcium homeostasis
CATCH 22

Cardiac defects
Abnormal facial features
Thymic aplasia
Cleft palate
Hypocalcemia
and chromosome 22.
Hyper IgM syndrome
Serum levels of immunoglobulin in
Hyper IgM syndrome

IgG↓

IgA IgM
↓ ↑↑

IgE↓
Hyper IgM syndrome
• Defect in CD40 ligand

CD40
ligand
CD40
T cell
B cell
Ig Class
switch
 Hyper IgM
• Patients cannot make a switch from IgM to
other classes which is attributed to a defect in
CD40L on their CD4 cells.
 Diagnosis of Immunodeficiency
• The diagnosis is probable when blood tests
show the complete lack of circulating B cells
(determined by the B cell marker CD 19
and/or CD 20),

• As well as low levels of all antibody classes,

including IgG, IgA, IgM, IgE and IgD.
 Treatment for Immunodeficiency
• Intravenous or subcutaneous immunoglobulin
replacement is the first-line treatment.
• The best treatment for T-cell deficiency conditions is
bone marrow transplant, if a donor can be found.
• In chronic disease, the prognosis has improved with
robust and early treatment of bacterial infection
and advances in antiviral therapy such as highly
active antiretroviral therapy (HAART) in AIDS.
 Tests used to diagnose Primary and
Secondary ID
• Agglutination reaction
• Precipitation reaction

• Quantification of Immunoglobulin
• Protein electrophoresis
• Immuno-electrophoresis
Ag-Ab reactions
Tests for Ag-Ab
reactions
 Specificity
• The ability of an individual antibody combining site to
react with only one antigenic determinant.
• The ability of a population of antibody molecules to
react with only one antigen.
Agglutination Tests

Lattice Formation
 Agglutination/Hemagglutination
• Definition - tests that have as their endpoint
the agglutination of a particulate antigen
– Agglutinin/hemagglutinin
• Qualitative agglutination test
– Ag or Ab

+ 
 Agglutination/Hemagglutination

• Applications
– Blood typing
– Bacterial infections
– Fourfold rise in titer
Passive Agglutination/Hemagglutination
• Definition - agglutination test done with a
soluble antigen coated onto a particle

+ 

• Applications
– Measurement of antibodies to soluble antigens
Precipitation Tests
Lattice Formation
 Radial Immunodiffusion (Mancini)

• Method Ab in gel

– Ab in gel Ag Ag Ag Ag

– Ag in a well
• Interpretation
– Diameter of ring is
proportional to the
Diameter2
concentration
• Quantitative
– Ig levels

Ag Concentration
 Immunoelectrophoresis
• Method
– Ags are separated by electrophoresis
– Ab is placed in trough cut in the agar

+ -
Ag Ag

Ab

Ag

Ab

• Interpretation
– Precipitin arc represent individual antigens
 Countercurrent electrophoresis
• Method
– Ag and Ab migrate toward each other by
electrophoresis
– Used only when Ag and Ab have opposite charges

- +
Ag Ab

• Qualitative
– Rapid
 Radioimmuoassays (RIA)
Enzyme-Linked Immunosorbent Assays (ELISA)

Lattice formation not required

 Competitive RIA/ELISA for Ag
• Method
– Determine amount of Prior to Test
Ab needed to bind to
a known amount of + 
labeled Ag Labeled
Ag
– Use predetermined
Test
amounts of labeled Ag
and Ab and add a
+ +  +
sample containing
Labeled Patient’s
unlabeled Ag as a Ag sample
competitor
 Solid Phase Non-Competitive RIA/ELISA
• Ab detection
– Immobilize Ag Labeled
Anti-Ig
– Incubate with sample Ab in
– Add labeled anti-Ig Patient’s
sample
– Amount of labeled Ab
Immobilized Ag
bound is proportional
to amount of Ab in the Solid
sample Phase

• Quantitative
Tests for Cell Associated Antigens
Lattice formation not required
 Immunofluorescence
• Direct
– Ab to tissue Ag is labeled with fluorochrome

Fluorochrome
Labeled Ab

Ag
Tissue Section
 Immunofluorescence
• Indirect
– Ab to tissue Ag is
unlabeled Fluorochrome
Labeled Anti-Ig
– Fluorochrome-labeled anti- Unlabeled
Ab
Ig is used to detect binding
of the first Ab.
Ag
• Qualitative to Semi- Tissue Section
Quantitative
 Immunofluorescence
• Flow Cytometry
– Cells in suspension are labeld with fluorescent tag
• Direct or Indirect Fluorescence
– Cells analyzed on a flow cytometer

Flow
Tip FL
Detector

Light
Scatter
Detector

Laser
 Immunofluorescence
• Flow Cytometry cont.
– Data displayed

One Parameter Histogram Two Parameter Histogram

Green Fluorescence Intensity

Unstained cells
Number of Cells

FITC-labeled cells

Green Fluorescence Intensity Red Fluorescence Intensity

Assays Based on Complement
Lattice formation not required
 Complement Fixation
• Methodology
– Ag mixed with test serum to be assayed for Ab
– Standard amount of complement is added
– Erythrocytes coated with Abs is added
– Amount of erythrocyte lysis is determined

Ag No Ag
Ag
Patient’s
serum
Ag
 Tests
• Serum protein Electrophoresis & Quantitation of Ig
• Immunoelectrophoresis
• Spontaneous Rosette
• ABO and Rh grouping
• Hepatitis B & C, Syphilis
• HIV
• Chagas disease
• Direct and Indirect Coombs
• Compatibility testing
• HTLV